Attention Men: You May Not Need Prostate Surgery

If you're a man over age 50, chances are you find yourself running to the bathroom more often than you once did.

Until recently, doctors were quick to attribute these symptoms to an enlarged prostate-a noncancerous condition known as benign prostatic hyperplasia (BPH)—and prescribe drugs to shrink or relax the gland, or surgery to reduce its size.

The prostate is a walnut-sized gland that lies just below the bladder. It produces the fluid in semen that helps nourish sperm. As a man ages, the prostate usually enlarges-perhaps due to normal hormonal changes-sometimes leading to such symptoms as trouble urinating.

Latest development: Researchers now strongly suspect that the prostate may be only partially responsible for the symptoms usually blamed on BPH—or, in some cases, not at all. This means that many men may be able to avoid prostate surgery altogether if the problem is properly diagnosed.

The Hidden Culprit

Because the prostate is located next to the urethra (the tube that carries urine from the bladder), the flow of urine can become partially obstructed when the gland enlarges. As a result, the urinary stream becomes weaker. Other "obstructive" symptoms include hesitancy (it takes longer to start urination) and intermittency (the flow stops and starts repeatedly during urination).

What's new: Other urinary problems, called "irritative" symptoms-urgency (a strong, sudden need to urinate)...frequency (repeated trips to the bathroom)...and nocturia (excessive need to urinate at night)are now believed, in some cases, to be only indirectly related to an enlargement of the prostate and/or may have more to do with the bladder.

One possible reason: When the prostate compresses the urethra and obstructs urinary flow, the bladder may not empty completely. Bladder muscles grow stronger to overcome the obstruction, possibly making the bladder harder to control.

Diagnosing The Problem

Prostate enlargement can be diagnosed with a digital rectal examination (the doctor inserts a gloved finger into the rectum and feels the prostate). But prostate size alone can be misleading—it's only when the gland grows inward that the urethra becomes compressed and urinary problems develop.

Although other tests are available to check urinary and bladder function, the majority of doctors simply suggest a trial of prostate medication. If a prostate drug relieves the symptoms, the diagnosis can be safely assumed to be BPH.

The Conventional Approach

The majority of men with obstructive symptoms (slow start, slow stream and/or incomplete emptying) get relief from two types of medication commonly used for BPH. The drugs work in different ways-one type may help when the other fails, and both types used together may be more effective than either alone.

• Alpha blockers, such as terazosin (Hytrin), alfuzosin (Uroxatral), doxazosin (Cardura) and tamsulosin (Flomax), relax the smooth (involuntary) muscles in the prostate and the neck of the bladder, loosening their grip on the urethra. These drugs usually relieve urinary symptoms within one week.
  

Side effects: Low blood pressure when you stand up and/or dizziness. These side effects typically resolve within three days.

Caution: Alpha blockers can cause complications during cataract surgery. If you take an alpha blocker, tell your doctor before undergoing a cataract operation.

• 5-alpha reductase inhibitors, such as finasteride (Proscar) and dutasteride (Avodart), interfere with the conversion of testosterone into dihydrotestosterone, the active form of the hormone that stimulates the prostate to grow. These drugs can shrink the gland and are particularly useful when the prostate is very large.
  

But they can take months to work-and are often less effective than alpha blockers.

Side effects: Decreased libido and impotence in 3% to 10% of cases.

The New Approach

In a groundbreaking study recently published in the Journal of the American Medical Association, 879 men who had both obstructive and irritative urinary symptoms were divided into groups that were given the prostate drug tamsulosin...tolterodine (Detrol), a drug for overactive bladder (a condition that causes urinary frequency, urgency and/or nocturia)...a placebo...or both drugs.

The bladder drug, the prostate drug and the placebo were equally effective in reducing both types of urinary symptoms. The drug combination, however, was significantly more effective than either drug alone-symptoms improved in 80% of men who received it.

Self-defense: If you experience urinary frequency, urgency and/or nocturia that has not been adequately relieved by the use of prostate drugs alone, see a urologist to determine whether a combination of prostate and bladder drugs may help.

Surgical Options

If an overactive bladder drug doesn't bring relief within two months, and prostate drugs do not do so within a few months, surgery may be necessary.

Options include…

• Transurethral resection of the prostate (TURP) is the most effective for BPH and rarely requires repeat surgery. Instruments inserted through the urethra remove parts of the prostate to widen the path for the flow of urine. It requires general or spinal anesthesia and a hospital stay.
  

Complications: Rarely, impotence and urinary incontinence occur.

• Transurethral microwave therapy (TUMT) uses a microwave antenna that produces heat to shrink the prostate. It does not require anesthesia and can be performed in a doctor's office. TUMT generally is less effective than TURP, and some men require further treatment within several years.
  

Complications: Similar to those with TURP, though even less common.

• Photo vaporization prostate (PVP) is a type of laser therapy that precisely targets the part of the prostate that the surgeon wants to destroy. Like TUMT, repeat treatment can be required. PVP is performed on an inpatient or outpatient basis.
  

Complications: Similar to those with TURP, though even less common.

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